Laserfiche WebLink
i <br /> APPLICATION FOR PERMIT <br /> F <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j <br /> ENVIRONMENTAL HEALTH DIVISION I <br /> 1601 E. HAZELTON' AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> Uj'MIT E%PIRES J YEAR FROM DATE ISSTVn <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ttcc��� <br /> X59 B Dov �- �� Lot Size/Acreage kv � <br /> Joh Address City rr <br /> Pon r Phone �b^ <br /> Owner's Name Address <br /> Contractor -- <br /> Address 12k5 ryt^ License No. y y� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ELL REPLACEMEN 11DESTRUCTION LI Out of Service Well LI <br /> Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REP R ❑ <br /> OTHER 171 ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN S DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTU WEL OTHER WELL PITS/SUMPS <br /> INTENDED USE, TYPE OF WELL PROBLEM AREA CO RUCTION SPECIFICATIONS <br /> * Industrial <br /> 4 <br /> ' ❑ Open Bottom ❑ Manteca Dia f Well Excavation Dia. of Wel! Casing <br /> Casing— Specifications <br /> ® Domestic/Private 0 Gravel Pack L7 Tracy Pe g— <br /> t-1 Other f 1-1 Delta�- Depth o Grout Seal Type of Grout <br /> F) Public <br /> l ( Irrigation ApproxDepth ( 1 Eastern`" 'Surface al Installed by <br /> : <br /> Repair Work Done LJType of Pump, <br /> H.P y~ State Work DoneL <br /> sling`l+faterial'&.Depth <br /> Well Destruction ❑ Well Diameter s s ; ; _ <br /> Depth 'Filler Material & Depth <br /> TYPE•OF SEPTIC WORK: NEW INSTALLATION REPAIRJADDITION t I DESTRUCTION I 1 lNo•septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: R ldence Commercial^ ther <br /> Number of living unNumber f bedr oma � `b <br /> ' <br /> Character of soil to a depth of 3 feet: y`" No.C- table depth <br /> SEPTlC TANK. ($' TypelMlg Capacity�d No. Compartments <br /> PKG_TREATMENT PLT. ❑ r ' Method of Disposal <br /> Distance to nearest: Well'` 5 Foundation Property Liner <br /> LEACHING LINE No. & Length of lines p l CTotal length/size <br /> FILTER BED ❑ Distance to nearest: Well_ _ Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size �� Nrber <br /> SUMPS, l�+( Distance to nearest: Well % _x.Foundation Property Line S <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or'sub-contracting signature <br /> certifies the following:"I cenify that in a perfor nce of the work for which this permit'is issued, I shall employ persons subject to workman's compensa <br /> tion taws of California.,. �: t <br /> The applicant mus uired ins ti S. Complete drawing on r rse side. <br /> Title: Date:, /S <br /> Signed X _ "._ � <br /> �.. - s t� <br /> R DEPARTMENT USE ONLY _ <br /> A licati r A s <br /> I --- _ - - .. Date' ` — ` res A <br /> pp on Accepted by 1 <br /> Pis or Grout Inspection by Date Final Inspection by Dat <br /> ` Additional Comments: <br /> Applicant`- Return all copies to: San Joaquin County Public health <br /> Services, Enviroamental Health Permit/Services <br /> i 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201. <br /> FEEC!21 <br /> AMOUNT REMITTED CASFf RECEIVED BY DATE PERMil N0. <br /> INFO <br /> . EH 13.24 IAEV,i n 5) I R�� <br /> EH 14.26 <br />